RE: Entering MDS based on interviewing staff vs actual documentation

[Ann Schoeny]

You can start at section 1.14 and read what this says, but it is clear CMS does not impose any documentation in nursing facilities. BUT, since DAVE has been started, it is probably best to tighten up documentation to protect payment. I will often document in the mds section of the chart, ie "Resident and staff interviewed...blah blah..." I make this entry prior to the ARD. Does this help. The MDS was not meant to do all the things is is doing now, and we are getting more and more scrutinized from too many agencies....   -----Original Message----- From: Kathy Archibald [mailto:[EMAIL PROTECTED] Sent: Thursday, February 19, 2004 11:32 AM To: [EMAIL PROTECTED] Subject: Entering MDS based on interviewing staff vs actual documentation Could someone easily refer me to the section in RAI manual that says that it is OKAY to enter something in the MDS just from interview conversations with staff even if the nurses did not document this in the medical record.  Then, does the person entering the information in the MDS need to document it in the medical record? thanks. Kathy Archibald RN Living Center Supervisor FAX 1-208-547-2790 Voice 1-208-547-2771 email [EMAIL PROTECTED]